Abstract
The history of surgery is a very interesting tale in its complexity and its intricacy with wartime. Early American medicine was split into physicians and surgeons. These “general” surgeons provided all kinds of procedures all over the body. Surgical subspecialties began to emerge after surgeons would find an area of particular interest, create surgical advancement in this interest, and then self-limit their practice to that area. These self-proclaimed specialties would also give rise to news specialties as surgeons learned from each other. A prime example of the mixing of specialties generating new specialties is Sir Harold Gillies, a British otolaryngologist. Gillies is probably most well-known for his incredible advancements in craniomaxillofacial reconstruction during the First World War after working with numerous dental surgeons. He is often considered the father of modern plastic and reconstructive surgery. The roots of all the surgical subspecialties are tied, which is why overlap occurs between surgical specialties and no one area of specialty owns a particular body part or procedure.
As medical professionals, we know that different providers are experts in different things, some of which overlap with others and some of which do not. A provider’s scope of practice generally refers to a specific profession’s own self-described scope based on appropriate education, training, and experience. Scope of practice is where medicine crosses paths with the legal world. It is interesting to look at how the courts define an expert. In 1993, the U.S. Supreme Court articulated a test for permissible expert testimony in Daubert v. Merrell Dow Pharmaceuticals. This “Daubert Standard” instructs courts to permit an expert’s testimony on a technique if the technique has been tested, subjected to peer review, it has known complications, there exists standards and controls in the procedure, and has attracted widespread acceptance in the profession. 1 Therefore, the definition of who can be an expert witness has more to do with their ability to speak to the procedure, rather than what “specialty” they identify with. Interestingly, the Supreme Court of Arizona concluded in a 2013 case that “specialty,” for purposes of statutory requirements for expert witnesses, refers to a limited area of medicine in which a physician is or may become board certified; [and] “specialty,” for purposes of those statutory requirements, includes subspecialties and is not limited to the 24 member boards on American Board of Medical Specialties. 2 This court acknowledged that subspecialties exist outside of the specialties defined by the American Board of Medical Specialties.
An Arizona Court of Appels used this principal in a 2018 case to exclude an expert witness from testifying. The court concluded that the witness was not equivalent to the defending surgeon because the defending surgeon was certified in cosmetic surgery by the American Board of Cosmetic Surgery, but the expert witness was a plastic surgeon, board certified by the American Board of Plastic Surgery. 3 This case highlights the disconnect between the medical and legal system. As the court noted, “the proposed expert had experience that—as a practical matter—rendered him competent to opine on the medical procedures at issue.” He, therefore, should have been able to act as the expert witness for the case. He was, nevertheless, not permitted to testify because the law focused on his “specialty,” rather than his experience and training.
As surgery has evolved, we have become quick to define ourselves and try to highlight that we are different from other specialties, sometimes forgetting the roots of surgery—general surgeons. In the end, we are all doctors trying to care for our patients. To do it, we need to educate both the legal system, and more important, the patient population, about what procedures we offer and why we are competent to perform them. Plastic and reconstructive surgery started as reconstructive battlefield surgeons. These surgeons then used the principals they learned from repair of tissues as reconstructive surgeons on cosmetic procedures. As so many specialties have similar ancestries, many other surgical subspecialties have likewise trained in reconstruction and can relay those principals into cosmetics. Fellowships also provide additional training and help demonstrate that competency. It is not just the minimum 50 cases in facial cosmetics or 300 cases in general cosmetic procedures that make someone a cosmetic surgeon. It is this in conjunction of their years of medical training learning anatomy, physiology, pharmacology and using the surgical principals, and applying it into the world of cosmetics. While cosmetic surgery has deep roots in reconstructive surgery, it has its own unique qualities which is why it has developed into its own field. Repairing something that is broken is different than trying to attain someone’s ideal of beauty.
Cosmetic surgery has had a long battle of ownership as it has evolved into a lucrative and sought-after part of modern surgery. This battle of who can do what even exists in the world of minimally invasive procedures. As many are aware, oral and maxillofacial surgery (OMS) has both single- and dual-degree tracks. Many single-degree OMS do not perform injectables such as neuromodulators or dermal fillers because they believe they need a medical license or they are limited with their scope of dental practice. Injectables have become quite popular, and many different providers are performing these services including internists, family physicians, physician assistants, nurse practitioners, dermatologists, ophthalmologist, otolaryngologists—head and neck surgeons, plastic and reconstructive surgeons, and oral and maxillofacial surgeons. Physician assistants and nurse practitioners are qualified under the law to perform these procedures without medical degrees, which should demonstrate that it is about training and competency of the procedure and less about the degree or specialty.
It is vital to be competent in whatever procedure you are offering to patients because it provides reliable outcomes and would be unethical to perform a procedure that you are not competent in. Competency comes through education and experience. As cosmetic surgery is one of the most rapidly evolving surgical subspecialties, it is important to use continuing education. One of my favorite article titles is by Thompson and Roser: “Do the science, own the field, are we doing the science?” which essentially called for a renewed interest in research as those who were on the cutting edge were dominating that field. 4 This is true in all aspects of life and is true in cosmetic surgery. The surgeons who do the research and put out the newest advancements, continue to educate, and demonstrate their competency with good outcomes will own the field.